Adam F.
Barrison, MD
Department of Gastroenterology
Summit Medical Group
Typical symptoms of GERD
• Heartburn
• Regurgitation (an effortless return
of gastric contents into the esophagus and
frequently into the mouth; often confused with
vomiting)
Younes and Johnson. Gastroenterol Clin North Am 1999
Atypical symptoms of GERD
• Dysphagia • Chest pain
• Throat clearing • Hoarseness
• Globus • Chronic cough
• Laryngospasm • Sore throat
• Dental erosion • Wheezing
Mujica et al. Postgrad Med 1999
1
DeVault et al. Am J Gastroenterol 1999
2
Symptom patterns in GERD
• Reflux-related symptoms occur predominantly
after meals.
• Reflux-related symptoms are often triggered by
∗ unusually large meals
∗ bending, stooping, or lying down
∗ strenuous activities
• The frequency of reflux-related symptoms
varies widely
Johnsson et al. Gullet 1992
The GERD iceberg
Persistent symptoms and complications
Titanic
Frequent symptoms
(seen by MD)
Occasional symptoms
(not seen by MD)
Adapted from Castell Gastroesophageal Reflux Disease. Futura Publishing. 1985
Approximately half of all patients with reflux
symptoms have erosive esophagitis
Patients presenting
with reflux symptoms (n = 97)
Barrett’s
esophagus
Erosive esophagitis 46% 12%
42%
No erosive esophagitis
Winters et al. Gastroenterology 1987
Severity of heartburn symptoms does not predict
the presence of erosive esophagitis
100
80
Severe Heartburn Grade
Patients (%)
60
Moderate
40 Mild
20
0
EE Positive EE Negative
(n=316) (n=677)
The presence of erosive esophagitis should be diagnostically confirmed.
Venables et al. Scand J Gastroenterol 1997
Severity of GERD symptoms does not correlate with
severity of disease
No heartburn Mild heartburn
Patients with heartburn (%)
Moderate heartburn Severe heartburn
60
50
40
30
20
10
0
Grade A Grade B Grade C Grade D
(n=1466) (n=1634) (n=869) (n=314)
N=4283
Levine et al. Am J Gastroenterol 1999
Frequency of heartburn does not correlate with
the presence of erosive esophagitis
100
80 46 Heartburn frequency
58
% patients
60 7 days/wk
18 5 to 6 days/wk
40 2 to 4 days/wk
18
20 36
24
0
Endoscopy Endoscopy
negative positive
Smout. Aliment Pharmacol Ther 1997
Erosive Esophagitis
GERD is a chronic condition that is likely to relapse
100
No mucosal breaks
LA grade A
symptomatic remission
80
LA grade B
% patients in
60 LA grade C
40
20
0
0 1 2 3 4 5 6
Time after cessation of therapy (months)
Lundell et al. Gut 1999
GERD has a greater impact on quality of life
than other common diseases
“Normal” Score
67 Psychiatric patients
84 GERD (untreated)
85 Duodenal ulcer (untreated)
Population
87 Angina pectoris
94 Heart failure (mild)
101 Normal female
103 Normal male
105 Hypertension (untreated)
Worse 60 70 80 90 100 110 Better
Psychological General Well-being Index (PGWBI) score
Dimenäs. Scand J Gastroenterol 1993
Mechanisms that cause GERD
• Theophylline
• Anticholinergics
• TCA’s
• Progesterone
• Ca channel blockers
• Diazapam
Complications of GERD
• Esophageal: • Extra-esophageal:
- Barrett’s esophagus - Asthma
- Adenocarcinoma - Chronic Cough
- Stricture - Reflux laryngitis
- Ulceration - Dental enamel loss
- Bleeding - Vocal cord injury
- Subglottic stenosis
Endoscopy
• Allows direct mucosal visualization and biopsy
• Gold standard for diagnosis of erosive esophagitis
• Only method for reliable detection of Barrett’s
DeVault et al. Am J Gastroenterol 1999
Esophageal stricture
Barrett’s esophagus
Barrett’s esophagus – clinical significance
• Premalignant lesion for esophageal
adenocarcinoma
• Patients with Barrett’s esophagus may be
30 – 60 times more likely to develop this
cancer than the general population
• The reported incidence of adenocarcinoma
of the esophagus is rising
Lagergren et al. New Engl J Med 1999
The prevalence of Barrett’s esophagus
increases with the duration of reflux symptoms
25
Barrett's esophagus (%)
Prevalence of probable
21
20
17
15
11
10
5 4
0
<1 1 to 5 5 to 10 >10
Duration of symptoms (years)
Lieberman et al. Am J Gastroenterol 1997
Esophageal adenocarcinoma
The risk of esophageal adenocarcinoma
increases with the frequency of reflux symptoms
18 16.7
Odds ratio for esophageal
16
14
adenocarcinoma
12
10
8 6.3
6 5.1
4
2 1.0
0
None 1/week 2–3/week >3/week
Frequency of symptoms
Lagergren et al. N Engl J Med 1999
The incidence of esophageal adenocarcinoma
is rising
Connecticut Cancer Registry
1.2
National Cancer Institute *Greatest
1.0 increase in
Cases/100,000/year
Birmingham, England white males
0.8
Canton Vaud, Switzerland
0.6
0.4
0.2
0
1940 1950 1960 1970 1980 1990 2000
Pera et al. Gastroenterology 1993
Management options in GERD
• Lifestyle measures
• Medications
• Antireflux surgery
• Newer endoscopic techniques
What is the role of lifestyle factors in GERD?
Lifestyle factors probably play a lesser role in
the pathogenesis of GERD than originally
thought 1
.
Dent et al. Gut 1998
1
Lifestyle measures
• Raise the head of the bed, or lie on left side
• Decrease fat intake?
• Avoid certain foods
• Avoid lying down for 3 hours after eating
• Stop smoking
• Lose weight if appropriate
Dietary factors that may aggravate GERD symptoms
• Caffeinated products (coffee, tea, chocolate)
• Peppermint
• Fatty foods??
• Spicy and tomato-based foods
• Citrus foods and juices
• Alcohol
Evolution of pharmacological therapy
• Antacids (Tums, Rolaids)
• Prokinetics (Reglan, Cisapride)
• H2-receptor antagonists (Pepcid, Zantac)
• Proton pump inhibitors (Prilosec, Prevacid)
Mechanisms of Action
of GERD Medications
Prokinetics HCI Antacids neutralize
increase secreted HCl
esophageal
clearance and PPIs block acid at its
gastric emptying H+ K+ source in the proton
pump
H2RAs block the
histamine receptor,
interfering with one of
the stimulation
Gastrin pathways
ACh Histamine
ACh=acetylcholine
Stretta Procedure
• Approved by FDA in May, 2000
• Heat is applied to the deep layer in the lower esophagus
• Success rate similar to fundoplication:
∗ Complete resolution in 70% at 1 year
∗ Partial resolution in 10 -15% at 1 year
• Complication rate considered low:
∗ Pain
∗ Perforation
Post-procedure appearance
Enteryx
• Approved by FDA in April, 2003.
•Bio-compatible non-biodegradable liquid polymer
implanted in the wall of lower esophagus
• Success rate similar to fundoplication: 74% off
medications at 1 year
• Complication: Damage from injection outside of the
esophagus
• Recalled in October, 2005
